All lesbian, gay, and bisexual (LGB)* people are not the same. I’ve long been an advocate that it’s not “the LGB community”, it’s “the LGB communities“. Even within just the lesbian “community”, there are subgroups. Everyone has different experiences, needs, and expectations. There is no one universal experience, and no monolithic community.

The easiest example is gender nonconformity. Within lesbian and female bisexual communities, for example, there are women who dress and act more masculine (“butch”) and women who dress and act more feminine (“femme”). The same is true for gay and male bisexual communities. Another example is “coming out”. While it’s a common experience, it’s not universal. I myself never had to “come out” to my family because my family was very accepting.. Bisexual people who date/marry opposite sex partners may also not choose to come out.

Despite differences, we know that there are some generalities about LGB communities. We know that LGB people, as a whole, have higher rates of depression than their straight peers. But we also know that not all LGB people have depression. Could gender nonconformity be the key?

Portrait of a boy, c. 1800. A boy who looked like this might well end up with depression after being teased and bullied.

Today’s study looked at depression, gender nonconformity, and LGB status among young adults in the United States. They used data from the Add Health study. Add Health was a study that started in schools and continued through until the participants were up to 32. The participants in today’s study were age 18-32. 86.7-93.1% of the sample (women-men range) were heterosexual. The rest were mostly heterosexual, bisexual, mostly lesbian/gay, or lesbian/gay. Depression was measured with a validated scale. Sexual orientation was rated on a Kinsey-type scale. And gender non-conformity was measured with a scale of activities, including team sports, religious activities, video game use, housework, and social activities.

What were the results?

At first, it looked like all the non-heterosexual participants were at higher risk for depression. Bisexuals had more depressive symptoms than lesbian and gay participants. However once they controlled for gender nonconformity, lesbians and gay men did not have more depression symptoms than heterosexuals. Bisexual participants continued to have higher rates of depression and controlling for gender nonconformity.

Who tended to be gender nonconforming? Young men were more nonconforming than young women. Lesbians and gay men were more nonconforming than all the bisexuals (including mostly straight and mostly gay), who were about as nonconforming as straight participants.

And the depression? Young women were more depressed than men. Black, Latino, and Asian participants were also more likely to have it. The same was true for those with low parental education levels and families with financial problems. Participants who were gender nonconforming reported more symptoms of depression than those who were conforming.

Lastly, the researchers looked at whether that depression held over time. Gender nonconformity did not predict depression in the future. Bisexuals, lesbian, and gay young adults were also not at risk for future depression; only depression in the moment. However individuals who identified as mostly heterosexual continued to have higher rates of symptoms. Individuals who are Black, Asian, female, had low parental education levels, or severe family financial problems, continued to have depression symptoms.

What does this really mean?

LGB young adults as a whole continue to be at higher risk for depression. However, that risk appears to mostly be an effect of gender nonconformity as a young adult. Those who are gender nonconforming as young adults are at higher risk for depression as young adults, but six years later that risk goes away. Why? Gender nonconformity is visible, and likely to result in the individual being a target for discrimination, which can result in depression. But then why doesn’t it continue six years later? Either the discrimination reduces (teenagers can be notoriously mean to each other), or the individuals develop coping skills or move into a more accepting community.

Additionally, bisexuals and mostly heterosexuals are at higher risk for depression than lesbians and gay men. Why? Well, it might be because they can “hide” and look heterosexual. That means they don’t need to “come out”. But it also means there’s less acceptance and acknowledgement of their orientation. That could have big effects.

What do we do with this information?

First, we can keep an eye out for the gender nonconforming young adults in our communities, whether they’re straight, bisexual, gay, or somewhere in between. We can support them when they need it. And second, we can create a more accepting environment. The less discrimination and the more acceptance of gender nonconformity, the less depression we are likely to see. We can make the world a positive place to be for everyone.

*: Please note that although today’s article does not use the word “cis” throughout despite the implication. The study in question examined cis individuals. However in my language, I use “men/male” and “women/female” to refer to gender identity, not biologic sex. So the general statements I make are intended to be inclusive of both cis and trans individuals, who can be lesbian/gay, bisexual, or straight.

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female at birth. Depending on your history some of these tips will apply more or less to you.

Please remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender men should consider…

Talk with their doctor about their physical and mental health

Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.

Consider using birth control methods if applicable. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.

If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.

Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.

Maintain a healthy weight. While being heavy sometimes helps to hide unwanted curves, it’s also associated with heart disease and a lower quality of life.

Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health.

Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.

Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.

If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.

In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.

Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.

If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!

Your doctor may wish to do other tests, including…

Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.

Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.

If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

Welcome back to Open Minded Health Promotion! This week is all about how cisgender women who have sex with women, including lesbian and bisexual women, can maximize their health. As a reminder — these are all in addition to health promotion activities that apply to most people, like colon cancer screening at age 50.

All cisgender women who have sex with women should consider…

Talk with their physician about their physical and mental health

Practice safer sex where possible to prevent pregnancy and sexually transmitted infections. Some sexually transmitted infections can be passed between women. If sexual toys are shared, consider using barriers or cleaning them between uses.

If under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.

Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider using them in the safest ways possible. For example, consider vaporizing marijuana instead of smoking, or participate in a clean needle program.

Maintain a healthy weight. Women who have sex with women are more likely to be overweight than their heterosexual peers. Being overweight is associated with heart disease and a lower quality of life.

Exercise regularly. Weight bearing exercise, like walking and running, is best for bone health. But anything that gets your heart rate up and gets you moving is good for your body and mind!

Seek help if you’re struggling with self injury, anorexia, or bulimia. These issues are much more common in women than in men, and can be particularly challenging to deal with.

Cervical cancer screening/Pap smear. All women with a cervix, starting at age 21, should get a pap smear every 3-5 years at minimum. Human papilloma virus (HPV) testing may also be included. More frequent pap smears may be recommended if one comes back positive or abnormal.

Pregnancy testing, even if you have not had contact with semen. Emergency situations are where testing is most likely to be urged. Physicians are, to some extent, trained to assume a cisgender woman is pregnant until proven otherwise. If you feel strongly that you do not want to get tested, please discuss this with your physician.

BRCA screening to determine your breast cancer risk, if breast cancer runs in your family. They may wish to perform other genetic testing as well, and may refer you to a geneticist.

If you’re between the ages of 50 and 74, mammography every other year is recommended. Mammography is a screening test for breast cancer. Breast self exams are no longer recommended.

One note on sexually transmitted infections… some lesbian and bisexual women may feel that they are not at risk for sexually transmitted infections because they don’t have contact with men. This is simply not true. The specific STIs are different, but there are still serious infections that can be spread from cis woman to cis woman. Infections that cis lesbians and bisexual women are at risk for include: chlamydia, herpes, HPV, pubic lice, trichomoniasis, and bacterial vaginosis (Source). Other infections such as gonorrhea, HIV, and syphilis are less likely but could still be spread. Please play safe and seek treatment if you are exposed or having symptoms.

Cardiovascular disease (CVD) is the leading cause of death in the United States. And it’s growing, largely because the factors that lead to CVD are growing too: obesity, diabetes, high blood pressure, high cholesterol, diets based on meat, and physical inactivity. We have data on how CVD risk varies depending on sex, ethnicity, and socioeconomic status. But we don’t have strong data on how gay, lesbian, and bisexual peoples risk factors add up to actual CVD risk.

CVD risk is often calculated using data from the Framingham study, a massive multigenerational study started back in 1948. The risk calculators that still come from that study today are some of the most well validated calculators we have. A physician can plug in a few numbers and get a good estimate of your risk of having a cardiovascular-related event over the next few years. The calculators are publicly available, but really do need training to interpret.

Why do I bring up the Framingham study? Because the study I’m examining this week uses those same calculators and other factors to try to estimate the cardiovascular risk of lesbian, gay, and bisexual cisgender people. Let’s take a look at what they did!

This study used data from the National Longitudinal Study of Adolescent to Adult Health. They used data from a whopping 13,427 participants. That’s a lot of people — one of the largest sample sizes covered here on Open Minded Health. The participants were also quite young for a study on heart disease — mostly around 28-29 years old. They looked at social factors like age, ethnicity, educational level, and level of financial stress. They also looked at medical factors, like their diabetes status and hypertension (high blood pressure) status.

The researchers reported sexual orientation on a Kinsey-like 5-point scale, from “heterosexual” to “mostly heterosexual” to “bisexual” to “mostly homosexual” to “homosexual”. I’ll try to stick to that language for clarity. Among the participants, 80% of the women and 93.5% of the men said they were heterosexual. In contrast, .9% of the women and 1.7% of the men said they were homosexual, and 18.7% of women and 4.8% of men were in the middle.

So what about their cardiovascular risk?

The men’s 30 year CVD risk was 17.2%, and the women’s was 9%. What does that mean? It means the men has a 17% chance of having cardiovascular disease in the next 30 years. In other words, a little under 1 in 5 of the men would have CVD by the end of 30 years. By then, they’d be in their late 50’s. Roughly one in five men and one in ten women in the entire study would likely have cardiovascular disease by their late 50’s.

What happens when we look at sexual orientation?

For women: Compared to heterosexual women (9% risk), all other sexual orientations were at higher risk for cardiovascular disease. Mostly heterosexual women had the lowest of non-heterosexual women, at 9.8%. Mostly homosexual women had the highest, at 11.8%.

For men: Compared to heterosexual men (17.2% risk), some sexual orientations were at higher risk and some were at lower risk. Mostly heterosexual and completely homosexual men were at lower risk of cardiovascular disease — 16.3% and 16.6% respectively. In contrast, mostly homosexual men had higher risk, at 20.2%!

What factors other than sexual orientation came into play? Risks were lower with more education. Being a college graduate reduced risk from 3% for women to 5% for men. Being of Asian or Hispanic descent was also protective, though not nearly as much. And the factors that increased risk? Being of African descent (up to 1% higher), being older (up to 1.5% higher), and having financial stress (up to 1.2% higher).

Let’s summarize a bunch of those numbers, shall we?

Overall, men are at twice the risk for cardiovascular disease as women. Non-heterosexual women are at higher risk than heterosexual women. Among men, mostly heterosexual and completely homosexual men were at lowest risk and mostly homosexual men were at the highest risk. Among everyone, poorer black people were at higher risks and richer, more educated hispanics and asians were at lower risks.

Why such a difference?

It’s hard to say. The researchers don’t go into detailed statistics to figure it out. I have some thoughts from looking over the data they published though. For women, it looks like part of that increased risk is from smoking — it looks like a higher percentage of non-heterosexual women smoked. On the male side, it looks like diabetes may play a role. But I haven’t run statistics to see if what I think I’m seeing is real or just by chance.

Regardless — this is valuable information which will help public health officials determine where to put their resources.

What can you do with this information? You can work to reduce your own cardiovascular risk! Here are some things to consider doing (depending on what works for you!):

Move more, eat less. Most Americans eat too much and don’t move enough, which leads to obesity and cardiovascular disease.

Stop smoking. Much easier said than done, but this is one of the best things you can do for your health

If you have diabetes, keep your blood sugar under control as best you can. Aim for the lowest HbA1c you can, but under 7% is a great place to be. If you haven’t spoken with a diabetes nurse educator, they can be great allies.

If you have hypertension, keep it under control as best you can. Take your medications, and talk with your doctor about them.

Get some healthy stress relief. Whether that’s a long hot bath, a fitness class, a long walk/run in the wilderness, or knitting a scarf — find something that helps you relax every day.

What is Open Minded Health?

OMH is dedicated to providing information about gender and sexual minority health. Posts are a mix of the latest research, activity risk reduction tips, and the latest news.

This blog is definitely not suitable for children, and probably not work safe. It contains descriptions of sexual activities that may disturb some readers.

Also please be aware: I am not a doctor. OMH does not provide health care advice - the information here is to be used as information only. It does not substitute a visit to your health care provider. When in doubt, please ask your health care provider.

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